15. Differences in Therapy - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Ouch! Where'd that come from?! The Borderline in Couples and Couple Therapy
Chapter 15: DIFFERENCES IN THERAPY


Therapy that includes the individual with borderline personality disorder includes both similarities and differences when working with other clients.  The therapist must be knowledgeable and conceptually clear about borderline personality disorder's effects on the individual, the partner, and the relationship.  The therapist should share this knowledge with the couple.  Psychoeducation about the individual with borderline personality disorder for both the individual and his or her partner is often critical to both members of the couple accepting the challenge of working to heal the attachment wounds and manage the toxic behaviors.  Knowledge about borderline personality disorder must be used to predict what the individual will do with his or her partner, the reactions elicited from the partner, and critically to the entire therapy, the reactions elicited from the therapist.  When the therapist can anticipate what his or her likely reactions and responses will be, he or she can avoid perpetuating dysfunctional borderline actions and reactions.

RESPONDING DIFFERENTLY
The individual with borderline personality disorder has a profound ability to get other people to fulfill their worse expectations in relationships.  While terrified that he or she will be betrayed, abandoned, or rejected, the individual almost inevitably stimulate and provoke the partner into behavior that fulfills the fear/prophecy.  The partner despite enormous effort and commitment to love and support the individual, either gets accused of negative behavior, get seduced or induced to behave poorly, or both.  When the individual and the couple enter therapy, the therapist often finds him or herself accused as well, and/or gets stimulated and provoked into rejecting thoughts and a wish to abandon (Selena was tempted to terminate therapy with Frieda).  Therapy seeks to get the individual to respond differently when triggered by his or her borderline emotional reactivity; and to get the partner to respond differently to the individual's borderline behaviors.  To achieve these changes in the members and the couple, the therapist's goal in therapy is also to respond differently than others have responded before to the individual's borderline behavior.  Key to reacting differently is the ability to be simultaneously intimately involved with the individual and couple while observing self and others.  "The difference in the therapy is that the therapist both experiences the patient's representation of the interaction and nonjudgmentally observes and comments on it (within the psychoanalytic literature, which is known as the third position).  This process is facilitated by the therapist's establishing a treatment frame (e.g., contract), which, in addition to providing structure and holding for the patient and a consensual reality from which to examine acting out behavior, minimizes the therapist's potential for acting in iatrogenic ways.  The therapist does not respond to the patient's fragmented one-dimensional partial representation but helps the patient observe it and the implied other that is paired with it" (Levy et al., 2006, page 488).

If the therapist is unaware of his or her countertransference, he or she may be triggered to react in ways that create adverse effects on the individual's and the couple's functioning.  The therapist must be aware of his or her instinctive reactions, and evaluate them for cues to the individual's or couple's process.  If the therapist is hurt, angered, mystified, or feels criticized or humiliated by the individual's words or behavior, the instinctive reaction may be to strike back, reassert oneself, seek clarity, be defensive and so forth.  Therapist reactivity as much as the individual's or the partner's reactivity comes from responding to another person's behavior with little or no awareness of any larger or deeper context.  While Selena complained about Frieda in the couple therapy, she was self-aware of her hurt, frustration, and anger towards Frieda and sought consultation.  Selena as a responsible therapist looked to understand the larger or deeper context of their dynamics.  Instinctively and theoretically, as a seasoned therapist Selena knew that her reactions would lead to confirming Frieda's fears about intimate figures betraying her again.  In order to avoid reacting in some repetitious unproductive pattern, a person  "needs to delay the response and come up with something new and different, that will in some way acknowledge the contextual similarity of the triggering stimulus.  Thus, the first step in switching from a reactive to a conductive stance is:

(a) to stop and not react;

(b) think through a reactive answer that we know would escalate the interchange; and

(c) substitute for the original reactive answer a different and positive response that will not hook up negatively the original producer of the initial stimulus.

Here one needs to be committed to positive and creative change.  Positive change implies progression rather than status quo (reactivity), or regression (apathy)" (L'abate, 1983, page 280).  Since the therapist is aware that he or she does not normally experience such feelings, he or she becomes aware the individual has not acted as a "normal neurotic" client.  When the therapist considers what has caused the individual to have such an intense reaction, he or she should quickly consider and probably eliminate any abusive actions on his or her part.  This may be difficult for the therapist if he or she is personally or professionally insecure and prone to guilt or shame.  Once clear that nothing should have ignited such a reaction, then conceptual clarity should consider that it must be because the individual feels betrayal, abandonment, or rejection- that is, manifesting borderline personality experiential anxiety.  Recognition of the individual's borderline tendencies and defensive style directs the therapist to alter his or her response.  He or she can then choose judiciously to react in some non-instinctive manner- a different response that is more therapeutic.  The therapist's response to a personal/professional assault is therefore his or her intervention for the borderline defense behavior.  The therapist teaches the partner to try to prompt a healthy ego response from the individual that supports self-care and autonomous functioning.  Interventions can focus on making the individual aware of his or her maladaptive and self-defeating borderline behaviors.  The therapist should confront helpless and incompetence assertions that submit to the omnipotence of the intimate other and/or "externalization of the source of the dysphoria of the abandonment depression.  The intervention thereby supports the underdeveloped reality ego of the patient, real self-expression, and independent activity" (Roberts, 1997, page.135).  The therapist must maintain a third-person perspective that watches his or her first person interactions with the individual and the partner- the second persons.  

"Frieda, I noticed that earlier when I agreed that Cliff must have had a hard time, you criticized my judgment by saying sarcastically, 'How would you know it was hard?'  When I told you about my experience with doing that, I saw that you crossed your arms and wouldn't look at me.  I could feel that you were mad at me for being on Cliff's side.  You're still kinda mad at me now.  Do you feel you need to punish me for hurting you?  It's hard for you to feel that I've let you down… betrayed you because I'm the authority that is supposed to be on your side.  Agreeing with your partner feels like I've cut you loose- abandoned you, Frieda.  But I'm not rejecting you even though you may feel I rejected you earlier.  Other people- your parents dismissed you, but that's not what I was… that I am doing.  I can see Cliff's point of view without rejecting or abandoning you.  It's not either one of you and not the other.  My deal is to support you by challenging you.  Remember how I talked to you, Frieda and you, Cliff about doing this in the first session?  How is this working for you?  My giving you feedback on what I'm feeling and seeing going on?  How does it feel?  Still feel hurt?  Still angry?  Talk about what is going on in you.  See what you find out about what you're feeling and thinking.  Try to let go of being angry or shutting down.  That's what you usually do.   You told me that.  Try something different.  Take a chance.  Or, if you can't stop yourself or do something different right now, pay close attention to yourself… to your feelings, thoughts, and how you're choosing to do or not do.  Remember all that, so we can talk about it later. Okay Frieda?"

An important role of therapy and the therapist is to offer alternative perspectives and interpretations… different points of view than the individual and the couple have habitually occupied.  The key is that these are different than the ones that have kept the individual and couple stuck, unhappy, and unfulfilled.  The therapist as active participant and also active observer can offer alternative insight and suggestions only if he or she is not immersed in the borderline drama.  The therapist may find consultation with another professional about working with borderline personality disorder useful to keeping the third-person perspective necessary for successful work.  The therapist is not only vulnerable to losing the third-person perspective, but likely to lose him or herself as the individual with borderline personality disorder is so adept at seducing, coercing, or forcing others into his or her "bad" intimate roles and expectations.  Personal professional style may enable the therapist (along with significant skill) to use humor to deflect or lessen intense borderline emotions.  Since the individual's demands to explain, defend, or justify words or behavior are skewed or filtered by borderline perceptions and interpretations, there are often no rational and intellectual responses that can satisfy him or her.  The therapist gets trapped- stuck as the individual with borderline personality disorder and the partner are stuck.

Humor, artfully used can deflect anger, accusations, and hopelessness.  "The intense, demanding, and dependent qualities of the relationship need to be attenuated.   Some borderlines can step back and examine an interaction in another perspective.  Even if the destructive interaction is simply terminated via the use of humor and not actually clarified, it may result in stress reduction in the family system" (Weddige, 1986, page 58-59).  Humor often intrinsically invokes and provokes an alternative intellectual perspective.  Common or normal perception or interpretations are purposely twisted or an odd or unique perspective presented that is strange… different… and perhaps, funny!  Humor can serve two vital purposes: one, to alleviate the emotional crisis as it red-lines beyond the individual and couple's capacity to hold together, and two, to get everyone unstuck.  Rigid intractable rules and standards for behavior are considered presumed to be unassailable, keeping everyone stuck.  Humor can break the loggerhead through proposing an outrageous or irreverent alternative- a third perspective.  Once a ridiculous (that is, funny) alternative is proposed, it prompts the individual, partner, and the couple to consider alternative views, choices, behaviors, and outcomes.  In addition, artfully expressed humor can be very supportive and nurturing to each member, while simultaneously challenging poor choices.  Humor is often a method for the therapist to maintain his or her psychic balance dealing with the stress from client's anxiety, depression, pain, loss, and crises.  It offers perspective to create distance between the therapist self and client within the fundamentally intimate therapeutic relationship.  Maintaining the therapeutic boundaries and therapist role is more challenging with the individual with borderline personality disorder relative to the "normal neurotic" client.  In other words, the third-person perspective, humor, or by other means, the therapist effectively must not allow the individual with borderline personality disorder to prompt him or her to react like a therapist with borderline personality disorder!

With the particularly problematic and intense client such as the individual with borderline personality disorder (in perhaps, a cynical perspective), the therapist should strongly consider not doing what the individual wants him or her to do!  If the individual seeks reassurance, don't!  If the individual wants an answer, don't!  If the individual seeks an omnipotent wise parental figure, refuse!  Whatever borderline motivated desire or demand is expressed, the therapist may assume that compliance could further reinforce dysfunctional dynamics.  The therapist should not be so rigid and must use clinical judgment, but at the same time should consider that the individual's instincts are fundamentally flawed.  Among different responses, rather than respond directly, the therapist can consider:

Paradoxical interventions combined with psycho-education,

Identify patterns, feelings of desperation,

Plan for the next incident (because there will be a next incident… and another… and another,

Teach how to express pain and loss without attacking,

Take away the right to abuse if hurt (self-righteousness).  

In couple therapy, the therapist should reinforce the partner setting limits on hurtful behavior by the individual with borderline personality disorder when her or she is feeling hurt.  The therapist might consider using predictions (paradoxical) of the continued behavior pattern.  Clinical judgment would need to determine if paradoxical or other interventions are appropriate and safe to attempt.  The therapist can help both the individual with borderline personality disorder and the partner create plans (concrete plans, including verbalizations, timeouts, amends) for dealing with crises.  The cycles of hurt and vengeance must be interrupted or the relationship is doomed.  Unfortunately, couples present after numerous years (or generations) of cycles of hurt, vengeance, forgiveness, and hurt again.  Presenting for couple therapy is in itself dangerous, because all the hurtful issues will be revisited.  Couple therapy can easily become another forum for recriminations.  Cognitive interventions may be well received.  The individual with borderline personality disorder often tends to be very intelligent.  However, the individual with borderline personality disorder easily sabotages rational-based or cognitive interventions because of his or her deeper internal pain and processes.

Therapy with the couple with such an individual requires great sensitivity, awareness, knowledge, and strong clinical skills.  "...the borderline patient who reacts with angry disruption or suicidal behavior to a therapy which he intuitively recognizes is inappropriate to his intense personal suffering, such as marital counseling or so-called touching and feeling treatments sometimes dignified by the label 'gestalt,' is not showing an increase in psychopathology but rather an increase in desperation and disappointment in yet another 'encounter' with lack of empathy and inappropriate misunderstanding of his basic needs by a parent figure" (Chessick, 1976, page 544).  The therapist should anticipate that the individual's intuitive perception tends toward a paranoid anticipation of more betrayal, abandonment, and rejection, and therefore plan to handle his or her disappointment therapeutically.  Failure to anticipate the reaction is virtually theoretical and clinical negligence.  Conceptual knowledge of the borderline roots or vulnerability empowers the therapist to use the individual's reaction as additional clinical information to alter the encounter rather than considering it to be a disruption of therapy.  It is business as usual when working with the individual with borderline personality disorder.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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